Socioeconomic Inequalities In Prevalence And Control Of Hypertension Of The Rural Elderly In Shandong Province, China

BackgroundChina has a large and growing aged population.In 2000,the population aged 60 and above reached 130 million in China,and was expected to rise to 438 million in 2050. There was a heavy burden of hypertension and cardiovascular disease in aged Chinese population.In 2003,the direct economic burden of six chronic noncommunicable diseases,including hypertension,cerebrovascular disease,and cardiovascular disease, was 34 billion(Chinese Yuan) in the Chinese population aged 65 and over,which accounted for six percent of gross health expenditure of China.The rural the elderly accounts for two thirds of the aged Chinese population.The burden of hypertension of the rural elderly was heavier than that of the urban elderly.In 2002,the prevalence of hypertension was 47%in rural adults aged 60 and above,a little lower than that in urban aged population.But the awareness,treatment and control of hypertension were much poorer in the rural elderly than that of the urban elderly.It is practically important to study socioeconomic inequalities in hypertension of the elderly.The health status of the elderly is poorer than younger population.What's more important is that there are internal differences within the elderly.Domestic and international evidence indicated that the health status of the elderly with poorer socioeconomic status was worse than that of the elderly with better socioeconomic status.If there are similar socioeconomic inequalities in prevalence and control of hypertension for the elderly,they deserve more concern from hypertension preventive strategies and more resources allocated on hypertension control.It is theoretically important to study socioeconomic inequalities in hypertension for the elderly.Measures of socioeconomic status on current use come from health inequality studies in developed countries.Most of these studies were set in developed industrial societies,and regarded labor force population,which was always aged from 16 to 64,as target population.Measures of socioeconomic status designed for labor force population may not be appropriate for the elderly.Furthermore,the social-demographic characteristics of rural the elderly in China are different from population of western developed countries.It is an unsolved problem to measure socioeconomic status for the rural elderlyObjectivesThe general objective of this study is to propose recommendations to improve the control of hypertension for the most vulnerable elderly in rural China,through describing socioeconomic inequalities in prevalence and control of hypertension for the rural elderly,identifying the subgroup which endures the heaviest burden of hypertension,and analyzing the determinants of socioeconomic inequalities in prevalence and control of hypertension.The following specific objectives are included: establishing an appropriate socioeconomic status measurer for the rural elderly in China;describing socioeconomic inequalities in prevalence and control of hypertension for the rural elderly;revealing determinants of socioeconomic inequalities in prevalence and control of hypertension;proposing recommendations to improve control of hypertension for the rural elderly. Design and participantsAnalysis of a cross-sectional study(n=20087),comprising household questionnaire survey and physical tests,from a program of chronic non-communicable disease control in rural areas of Shandong Province,China,conducted in April 2007.The target population of this study includes 4359 aged rural elderly who participated in both household survey and physical tests.MethodsIn the literature review,the conceptualization of socioeconomic status was discussed; measurers of socioeconomic status in common use and their applicability in the elderly in rural China were summarized.A theoretical framework in studying socioeconomic inequalities in prevalence and control of hypertension was established, based on the model of determinants of health inequalities.In order to identify the most vulnerable subgroup of the rural elderly conveniently,a composite socioeconomic status measurer "SES score" was established,based on Weber's definition of socioeconomic status and the social-demographic characteristics of the rural elderly in China.Meanwhile,three single-dimensional socioeconomic indicators(household education,per capita household expenditure,and individual disposable health budget) were used to explain the pathways through which socioeconomic status impacts prevalence and control of hypertension.After the discrimination of socioeconomic subgroups,this study described the socioeconomic disparities in prevalence of hypertension,exposure of hypertensive risk factors,hypertensive health utilization,hypertensive health expenditure,and control of hypertension for the rural elderly,and explained the determinants of these disparities.The statistical methods used included descriptive statistic methods, univariate statistical analysis,correlation analysis,multi-variate Logistic regression. The measurement of inequalities used included absolute difference of rates,adjusted odds ratio,concentration curve and concentration index.ResultsThe prevalence of hypertension was 67.2%for the rural elderly.The likelihood to be hypertensive was 22%lower in the elderly with mid-high SES score,compared with the elderly with the highest SES score.The difference in hypertension prevalence between the elderly with the lowest SES score and the elderly with the highest SES score was insignificant.The proportion of overweight was nearly 30%for the rural elderly.The likelihood to be overweight was 20%lower for the elderly with mid-high SES score,compared with the elderly with the highest SES score.The proportion of obesity was about 12%. The likelihood to be obese was 45%lower for the elderly with the lowest household expenditure,compared with the elderly with the highest household expenditure. Thirteen percent of the rural elderly experienced adverse life events during the previous year of the survey.The likelihood to experience adverse life events was 75% higher for the elderly with the poorest household education,compared with the elderly with the best household education.Thirty one percent of the rural elderly reported poor sleep quality.The likelihood to have poor sleep quality was 45%higher for the elderly with the lowest SES score,compared with the elderly with the highest SES score.The proportion of current smoker was 32%for the rural elderly.The likelihood to be current smoker was 49%higher for the elderly with the lowest household expenditure, compared with the elderly with the highest household expenditure.The prevalence of excessive alcohol intake was 9%for the rural elderly.The likelihood to intake excessive alcohol was 44%higher for the elderly with the lowest household expenditure,compared with the elderly with the highest household expenditure.The prevalence of high salt diet was more than 90%for the rural elderly.The likelihood to have high salt diet was 47%lower for the elderly with the lowest SES score, compared with the elderly with the highest SES score.Forty five percent of the rural elderly have sedentary life style.The likelihood to have sedentary life style was 84% higher for the elderly with the lowest SES score,compared with the elderly with the highest SES score.Less than 24%of the rural the elderly actively sought for health knowledge.The likelihood to be passive in seeking for health knowledge of the elderly with the lowest SES score was 2.6 times of that of the elderly with the highest SES score.Less than 22%of the rural elderly had knowledge of the relationship between diet and hypertension.Less than 25%of the rural elderly had knowledge of the relationship between smoking and hypertension.Less than 18%of the rural elderly had knowledge of the relationship between overweight and hypertension.The elderly with better socioeconomic status were more likely to have knowledge about hypertensive risk factors.Thirty three percent of the aged hypertensive patients were aware of their hypertensive diagnosis.Aged patients with the lowest household expenditure were 40%less likely to be aware of that they were hypertensive,compared with aged patients with the highest household expenditure.The proportion of taking drug treatment was 83%for self-reported aged hypertensive patients.Aged hypertensive patients with the smallest individual disposable health budget were 56%less likely to take drug treatment,compared with aged patients with the most individual disposable health budget.The proportion of taking non-drug treatment was 76%for self-reported aged hypertensive patients.The socioeconomic differences in non-drug treatment of hypertension were insignificant.Fifty five percent of the prescriptions of non-drug treatment received by the self-reported aged patients were qualified.The socioeconomic differences in prescriptions of non-drug treatment for hypertensive patients were insignificant.The mean cost spent on hypertension and its complications during the previpus year of the survey was 697 Chinese Yuan.The mean cost spent by aged patients with the lowest household expenditure was 2262 Yuan less than that spent by patients with the highest household expenditure.Twelve percent of the self-reported aged hypertensive patients experienced catastrophic burden of payment.The likelihood to experience catastrophic burden of payment was 2.9 times for aged patients with the lowest SES score,compared with aged patients with the highest SES score.Five percent of the rural older hypertensive patients had their blood pressure controlled.The socioeconomic disparities in hypertension control for rural older hypertensive patients were insignificant.Conclusions and RecommendationsThere was socioeconomic inequality in prevalence of hypertension for the rural elderly.The elderly with medium socioeconomic status were less likely to be hypertensive than their competitors with poorer and better socioeconomic status. There were socioeconomic inequalities in the exposure to hypertensive risk factors for the rural elderly.Compared with the elderly with better socioeconomic status,the elderly with poorer socioeconomic status were less likely to be exposed to physiological risk factors(overweight and obesity),but more likely to be exposed to psychological risk factors(experiencing adverse life events and having poor sleep quality),behavioral risk factors(smoking,excessive alcohol intake,sedentary life style,being passive in seeking for health knowledge),and health knowledge risk factors(having knowledge about hypertensive risk factors).There were socioeconomic inequalities in hypertensive health care utilization for aged hypertensive patients.Compared with aged patients with better socioeconomic status, Aged patients with poorer socioeconomic status were less likely to be aware of that they were hypertensive,and they were less likely to take drug treatment.There were socioeconomic inequalities in economic burden of hypertension for aged hypertensive patients.Aged patients with poorer socioeconomic status were more likely to experience catastrophic burden of payment than aged patients with better socioeconomic status.The socioeconomic differences in control of hypertension for aged hypertensive patients were insignificant.Currently,preventing exposure to hypertensive risk factors,advancing the awareness, treatment and control of hypertension should be main targets of strategies aiming to prevent and control of hypertension for the rural elderly.Subprojects of these strategies should pay more attention to specific socioeconomic subgroups of the rural elderly:1) weight control interventions and low salt diet promotions should concern more about the elderly with higher SES score;2) tobacco control and moderate drinking promotions should locate more resource to the elderly with poorer household economic status;3) psychosocial supportive interventions,physical exercise projects, and health education on non-communicable diseases should regard the elderly with lower SES score;4) hypertension preventive strategies aiming to decrease prevalence of hypertension should concern the elderly with both the highest and the lowest SES score;5) interventions for improve awareness of hypertension among patients should pay more attention to poorer elderly;6) programs for advance hypertensive treatment should regard the elderly with less individual disposable health budget;7) more resources from health insurance for hypertension should be allocated to the elderly with poorer socioeconomic status.